III-10. You are investigating the cause for a patient’s anemia.
He is a 50-year-old man who was found to have a
hematocrit of 25% on routine evaluation. His hematocrit
was 47% 1 year ago. Mean corpuscular volume is 80,
mean corpuscular hemoglobin concentration is 25, mean
corpuscular hemoglobin is 25. Reticulocyte count is 5%.
Review of the peripheral blood smear shows marked
numbers of polychromatophilic macrocytes. Ferritin is
340 g/L. What is the cause of this patient’s anemia?
A. Defective erythroid marrow proliferation
B. Extravascular hemolysis
C. Intravascular hemolysis
D. Iron-deficiency anemia
E. Occult gastrointestinal bleeding
III-12. A 73-year-old man is admitted to the hospital with 3
weeks of malaise and fevers. His past medical history is
notable only for hypertension controlled with a thiazide
diuretic. He smokes one pack of cigarettes per day and
works as an attorney. His physical examination is notable
only for a new systolic heart murmur heard best in the
mitral region. His laboratory examination is notable for
mild anemia, an elevated white blood cell count, and occasional
red blood cells on clean catch urine. Blood cultures
grow Streptococcus bovis and echocardiogram shows
a <1-cm vegetation on the mitral valve. What additional
evaluation is indicated for this patient?
A. Colonoscopy
B. Head CT scan
C. Pulmonary embolism protocol CT scan
D. Renal biopsy
E. Toxicology screen
III-17. A healthy 62-year-old woman returns to your clinic
after undergoing routine colonoscopy. Findings included
two 1.3-cm sessile (flat-based), villous adenomas in her
ascending colon that were removed during the procedure.
What is the next step in management?
A. Colonoscopy in 3 months
B. Colonoscopy in 3 years
C. Colonoscopy in 10 years
D. CT scan of the abdomen
E. Partial colectomy
III-26. Which of the following statements about cardiac
toxicity from cancer treatment is true?
A. Doxorubicin-based cardiac toxicity is idiosyncratic
and dose-independent.
B. Anthracycline-induced congestive heart failure is reversible
with time and control of risk factors.
C. Mediastinal irradiation often results in acute pericarditis
during the first few weeks of treatment.
D. Chronic constrictive pericarditis often manifests
symptomatically up to 10 years after treatment.
E. The incidence of coronary atherosclerosis in patients
who have a history of mediastinal irradiation
is the same as that in age-matched controls.
III-40. The triad of portal vein thrombosis, hemolysis, and
pancytopenia suggests which of the following diagnoses?
A. Acute promyelocytic leukemia
B. Hemolytic-uremic syndrome (HUS)
C. Leptospirosis
D. Paroxysmal nocturnal hemoglobinuria (PNH)
E. Thrombotic thrombocytopenia purpura (TTP)
III-47. Which of the following best describes the mechanism
of action of clopidogrel?
A. Activates antithrombin and inhibits clotting enzymes
B. Binds to the activated GPIIb/IIIa receptor on the
platelet surface to block binding of adhesive molecules
C. Inhibits cyclooxygenase 1 (COX-1) on platelets to
decrease production of thromboxane A2
D. Inhibits phosphodiesterase to block the breakdown
of cyclic adenosine monophosphate (cAMP) to inhibit
platelet activation
E. Irreversibly blocks P2Y12 to prevent adenosine
diphosphate (ADP)–induced platelet aggregation
III-59. Which of the following symptoms is most suggestive
of an esophageal mass?
A. Early satiety
B. Liquid phase dysphagia only
C. Odynophagia with chest pain
D. Oropharyngeal dysphagia
E. Solid phase dysphagia progressing to liquid phase
Dysphagia
III-72. Which of the following carries the best disease prognosis
with appropriate treatment?
A. Burkitt’s lymphoma
B. Diffuse large B cell lymphoma
C. Follicular lymphoma
D. Mantle cell lymphoma
E. Nodular sclerosing Hodgkin’s disease
III-75. A 48-year-old woman is admitted to the hospital
with anemia and thrombocytopenia after complaining of
profound fatigue. Her initial hemoglobin is 8.5 g/dL, hematocrit
25.7%, and platelet count 42,000/L. Her leukocyte
count is 9540/L, but 8% blast forms are noted on
peripheral smear. A chromosomal analysis shows a reciprocal
reciprocal
translocation of the long arms of chromosomes 15
and 17, t(15;17), and a diagnosis of acute promyelocytic
leukemia is made. The induction regimen of this patient
should include which of the following drugs:
A. All-trans-retinoic acid (ATRA, or triretinoin)
B. Arsenic
C. Cyclophosphamide, daunorubicin, vinblastine, and
prednisone
D. Rituximab
E. Whole-body irradiation
III-79. A 56-year-old patient inquires about screening for
colon cancer. He has no risk factors for colon cancer, other
than age. Which of the following statements is true regarding
which screening test you recommend for this patient?
A. 50% of patients with a positive fecal occult blood
testing have colon cancer.
B. One-time colonoscopy detects more advanced lesions
than one-time fecal occult blood testing with
sigmoidoscopy.
C. Perforation rates for sigmoidoscopy and colonoscopy
are equivalent.
D. Sigmoidoscopy has not been shown to reduce
mortality.
E. Virtual colonoscopy is as effective as endoscopic
colonoscopy for detecting polyps <5 mm in size.
III-102. A 46-year-old woman presents with new onset ascites
and severe abdominal pain: a hepatic Doppler examination
reveals hepatic vein thrombosis. She also reports tea
colored urine on occasion, particularly in the morning, as
well as recurrent worsening abdominal pain. On further
evaluation, she is found to have an undetectable serum haptoglobin,
elevated serum lactase dehydrogenase, hemoglobinuria
and an elevated reticulocyte count. A peripheral smear
shows no schistocytes. What is the most likely diagnosis?
A. Adenocarcinoma of the ovary
B. Antiphospholipid syndrome
C. Aplastic anemia
D. Factor V Leiden deficiency
E. Paroxysmal nocturnal hemoglobinuria
IV-14. A 17-year-old woman presents to the clinic complaining
of vaginal itchiness and malodorous discharge.
She is sexually active with multiple partners, and she is interested
in getting tested for sexually transmitted diseases.
A wet-mount microscopic examination is performed, and
trichomonal parasites are identified. Which of the following
statements regarding trichomoniasis is true?
A. A majority of women are asymptomatic.
B. No treatment is necessary as disease is self-limited.
C. The patient’s sexual partner need not be treated.
D. Trichomoniasis can only be spread sexually.
E. Trichomoniasis is 100% sensitive to metronidazole.
IV-28. A 32-year-old man presents with jaundice and malaise.
He is found to have acute hepatitis B with positive
hepatitis B virus (HBV) DNA and E antigen. Which of
the following antiviral agents are approved as part of a
therapeutic regimen for mono-infection with hepatitis B?
A. Efavirenz
B. Ganciclovir
C. Lamivudine
D. Rimantadine
E. Tenofovir
IV-36. The most common cause of traveler’s diarrhea in
Mexico is
A. Campylobacter jejuni
B. Entamoeba histolytica
C. enterotoxigenic Escherichia coli
D. Giardia lamblia
E. Vibrio cholerae
IV-45. In the inpatient setting, extended-spectrum -lactamase
(ESBL)-producing gram-negative infections are
most likely to occur after frequent use of which of the following
classes of antibiotics?
A. Carbapenems
B. Macrolides
C. Quinolones
D. Third-generation cephalosporins
IV-49. Which of the following is true regarding influenza
prophylaxis?
A. Patients receiving an intramuscular influenza vaccine
should be warned of the increased risk of GuillainBarré syndrome.
B. Patients with hypersensitivity to eggs should not receive
the intramuscular vaccine.
C. The intramuscular influenza vaccine is a live, attenuated
strain of influenza that is based on isolates from
the previous year’s strains of influenza A and B.
D. The intramuscular influenza vaccine should not be
given to immunocompromised hosts.
E. The intranasal spray, “Flu-mist,” is an inactivated virus
preparation based on the previous year’s strains
of influenza A and B.
IV-51. A patient presents to the clinic complaining of nausea,
vomiting, crampy abdominal pain, and markedly increased
flatus. The patient has not experienced any
diarrhea or vomiting but notes that he has been belching
more than usual and he describes a “sulfur-like” odor
when he does so. He returned from a 3-week trip to Peru
and Ecuador several days ago and notes that his symptoms
began about a week ago. Giardiasis is considered in
the differential. Which of the following is true regarding
Giardia?
A. Boiling water prior to ingestion will not kill Giardia
cysts.
B. Giardia is a disease of developing nations; if this patient
had not travelled, there would be no likelihood
of giardiasis.
C. Hematogenous dissemination and eosinophilia are
common.
D. Ingestion of as few as 10 cysts can cause human disease.
E. Lack of diarrhea makes the diagnosis of Giardia very
unlikely.
IV-60. In a patient with bacterial endocarditis, which of the
following echocardiographic lesions is most likely to lead
to embolization?
A. 5-mm mitral valve vegetation
B. 5-mm tricuspid valve vegetation
C. 11-mm aortic valve vegetation
D. 11-mm mitral valve vegetation
E. 11-mm tricuspid valve vegetation
IV-82. Several family members present to a local emergency
room 2 days after a large family summer picnic
where deli meats and salads were served. They all complain
of profuse diarrhea, headaches, fevers, and myalgias.
Their symptoms began ~24 h after the picnic. It
appears that everyone who ate Aunt Emma’s bologna surprise
was afflicted. Routine cultures of blood and stool
are negative to date. Which of the following is true regarding
Listeria gastroenteritis?
A. Antibiotic treatment is not necessary for uncomplicated
cases.
B. Carriers are asymptomatic but can easily spread infection
via the fecal-oral route.
C. Gastrointestinal (GI) illness can result from ingestion
of a single organism.
D. Illness is toxin-mediated, and organisms are not
present at the time of infection.
E. Person-to-person spread is a common cause of outbreaks.
IV-103. A 19-year-old woman comes to your office after being
bitten by a bat on the ear while camping in a primitive
shelter. She is unable to produce a vaccination record. On
physical examination, she is afebrile and appears well. There
are two small puncture marks on the pinna of her left ear.
What is an appropriate vaccination strategy in this context?
A. Intravenous ribavirin
B. No vaccination
C. Rabies immunoglobulins
D. Rabies inactivated virus vaccine
E. Rabies inactivated virus vaccine plus immunoglobulins
IV-111. In a patient who has undergone a traumatic splenectomy,
what test can be ordered to establish lack of
splenic function?
A. CT scan of the abdomen
B. Neutrophil migration studies
C. Peripheral blood flow cytometry
D. Peripheral blood smear
IV-118. A person with liver disease caused by Schistosoma
mansoni would be most likely to have
A. ascites
B. esophageal varices
C. gynecomastia
D. jaundice
E. spider nevi
IV-123. Which of the following represents an emergent
(same day) indication for cardiac surgery in a patient
with infective endocarditis?
A. Culture-proven fungal endocarditis
B. Culture-proven resistant organism with septic pulmonary
emboli
C. Prosthetic valve endocarditis 4 months after surgery
D. Sinus of Valsalva abscess ruptured into right heart
E. Staphylococcus lugdunensis in a patient with previous
history of endocarditis
V-17. A 30-year-old female is seen in the clinic before undergoing
an esophageal dilation for a stricture. Her past
medical history is notable for mitral valve prolapse with
mild regurgitation. She takes no medications and is allergic
to penicillin. Her physician should recommend which
of the following?
A. Clarithromycin 500 mg PO 1 h before the procedure
B. Clindamycin 450 mg PO 1 h before the procedure
C. Vancomycin 1 g intravenously before the procedure
D. The procedure is low-risk, and therefore no prophylaxis
is indicated.
E. Her valvular lesion is low-risk, and therefore no
prophylaxis is indicated.
V-18. A 78-year-old male presents to the clinic complaining
that every time he shaves with a straight razor, he passes
out. His symptoms have been occurring for the last 2
months. Occasionally, when he puts on a tight collar, he
passes out as well. The loss of consciousness is brief, he
has no associated prodrome, and he feels well afterward.
His past medical history is notable for hypertension and
hypercholesterolemia. His only medication is hydrochlorothiazide.
On physical exam his vital signs are normal,
and his cardiac exam is normal with the exception of a
fourth heart sound. Which of the following is the most
appropriate next diagnostic test?
A. Stress echocardiography
B. Adenosine thallium scan
C. Computed tomogram of the neck
D. Carotid sinus massage
E. Tilt table test
V-33. A 37-year-old male with Wolff-Parkinson-White syndrome
develops a broad-complex irregular tachycardia at
a rate of 200 beats per minute. He appears comfortable
and has little hemodynamic impairment. Useful treatment
at this point might include
A. Digoxin
B. Amiodarone
C. Propranolol
D. Verapamil
E. Direct-current cardioversion
V-57. Which of the following patients meets criteria for the
diagnosis of the metabolic syndrome?
A. A man with waist circumference of 110 cm, wellcontrolled
diabetes mellitus with fasting plasma
glucose of 98 mg/dL, and blood pressure of 140/75
mmHg
B. A woman with triglycerides of 180 mg/dL, waist circumference
of 75 cm, and polycystic ovary syndrome
C. A man with nonalcoholic liver disease, obstructive
sleep apnea, and blood pressure of 135/90 mmHg
D. A woman with high-density lipoprotein (HDL) of
54 mg/dL, blood pressure of 125/80 mmHg, and
fasting plasma glucose of 85 mg/dL
V-75. When treating a patient with a non-ST-segment elevation
myocardial infarction (NSTEMI), risk stratification
and timely administration of anti-ischemic and antithrombotic
therapies are paramount. For a patient with
unstable angina with negative biomarkers, which medication
regimen is most appropriate as initial treatment?
A. Aspirin, beta blocker, spironolactone, HMG-CoA
reductase inhibitor (statin)
B. Aspirin, clopidogrel, nitroglycerin, beta blocker, heparin
C. Aspirin, nitroglycerin, beta blocker, heparin, glycoprotein
IIB/IIIa inhibitor
D. Aspirin, morphine, oxygen, nitrates
V-82. Which of the following congenital heart defects
causes fixed splitting of the second heart sound?
A. Atrial septal defect
B. Epstein’s anomaly
C. Patent foramen ovale
D. Tetralogy of Fallot
E. Ventricular septal defect
VI-2. Which of the following associations correctly pairs
clinical scenarios and community-acquired pneumonia
(CAP) pathogens?
A. Aspiration pneumonia: Streptococcus pyogenes
B. Heavy alcohol use: atypical pathogens and Staphylococcus
aureus
C. Poor dental hygiene: Chlamydia pneumoniae, Klebsiella
pneumoniae
D. Structural lung disease: Pseudomonas aeruginosa, S.
aureus
E. Travel to southwestern United States: Aspergillus spp.